Management of impalpable testes: indications for abdominal exploration

Various approaches to the management of the impalpable testis in cases of cryptorchidism have been advocated. The authors' experience over the past 13 years was reviewed to try to determine an optimal approach. Of 1,305 patients with undescended testicles seen between February 1982 and December 1995, 157 boys (12.03%) had impalpable testes with 17 having bilateral impalpable testes for a total of 174 impalpable testes. A hernia sac was present in 155 impalpable testes with a testicle present in all cases. No hernia sac was found in 19 impalpable testes, five of which had no testicle present. This was confirmed by either open exploration or laparoscopy. One hundred forty-eight boys underwent groin exploration as initial treatment, 13 of these had bilateral impalpable testes. In addition to the five absent testicles with no hernia sac, one patient with a hernia sac and no testicle evident benefited from subsequent laparoscopy to identify an intraabdominal testicle. All other patients underwent routine orchidopexy or orchidectomy (one case with grossly malformed testicle). Nine boys underwent laparoscopy as initial treatment, four of these had bilateral impalpable testes. Two abnormal testicles were found and removed. Groin exploration and subsequent orchidopexy was definitive treatment in all other cases. The association of a hernia sac with an impalpable undescended testicle is very significant (P < .00001 Fisher's Exact test). The absence of a sac therefore may reflect an alternate diagnosis. When no sac is found with a testicle in the groin, this may represent an ectopic testicle. When no sac is found with no testicle, this may represent a vanishing testicle. From this experience the authors conclude that groin exploration should be the initial approach to impalpable testes. The presence of a hernia sac with an absent testicle demands further exploration; the absence of a hernia sac with an absent testicle suggests a vanishing testicle and may need no further exploration.     

Measurement of histidinohydroxylysinonorleucine and hydroxyproline in skin collagen by reversed-phase high-performance liquid chromatography after 9-fluorenylmethyl chloroformate labeling

The management of intra-abdominal desmoid tumors in patients with familial adenomatous polyposis (FAP) is very difficult. Non-steroidal anti-inflammatory drugs (NSAIDs), anti-estrogenic agents, and steroids are most commonly used, because surgical removal of these tumors may result in severe morbidity, with local recurrence being common. We report a patient with FAP and intra-abdominal desmoid tumors that regressed markedly after prednisolone therapy. The patient, a 38-year-old woman, had undergone total colectomy and ileorectal anastomosis with a diagnosis of FAP with colon cancer. Approximately 17 months after the surgery, she noticed an elastic firm lump in the abdominal wall. She also experienced lower abdominal distension. Computed tomography (CT) of the lower abdomen showed an invasive heterogenous low-density mass occupying the intra-abdominal space. She was treated with sulindac, NSAID, at 300 mg/day, the diagnosis being intra-abdominal desmoid tumors. She exhibited an intestinal obstruction about 9 months after the initiation of sulindac therapy. We changed the treatment and began prednisolone (initial dose, 40 mg/day). This treatment was continued for two years; subsequently, the lesions regressed markedly. She is currently well, more than 3 years after the withdrawal of prednisolone.     

Immediate recovery from acute renal insufficiency after abdominal decompression

A 61-year-old man received an aorto-iliac reconstruction after he was admitted because of a ruptured abdominal aortic aneurysm. Postoperatively, he developed cardiopulmonary insufficiency with anuria. After the intra-abdominal pressure had risen to 40 cmH2O (measured by a urinary bladder catheter), it was decided to perform a relaparotomy. Immediately after abdominal decompression--without correction of any other intra-abdominal pathology--the diuresis increased and several other cardiopulmonary parameters improved significantly. When a critically ill patient shows a rapid increase of the intra-abdominal pressure above a critical level an acute abdominal compartment syndrome may develop. This syndrome consists mainly of potentially fatal cardiopulmonary and renal insufficiency, for which (re)laparotomy with abdominal decompression is the only correct treatment.     

Necrotic testicle with increased blood flow on Doppler ultrasonic examination

A twelve-year-old male with a five-day history of scrotal swelling and pain had increased blood flow on ultrasonic examination. A testicular flow and scan indicated an ischemic testicle. Surgical exploration revealed complete torsion of the spermatic cord. In chronic cases of torsion, the Doppler stethoscope may give a false negative result because of reactive hyperemia.     

Evaluation of a new method for abdominal compression for use in oesophageal investigation

The use of conventional extra-abdominal compression with a constant cuff pressure was shown to give various pressures intra-abdominally in different subjects. A feedback system was therefore used, in which the extra-abdominal pressure is controlled by the intra-abdominal pressure. For an intra-abdominal pressure increase of 15 mm Hg the external cuff pressure in 20 subjects varied from 21 to 98 mm Hg. There was, however, an almost linear relationship between increased intra-abdominal pressure and cuff pressure. The extra-abdominal pressure required to obtain a certain intra-abdominal pressure also varied with the size of the cuff. To obtain relevant and comparable results in studies of hiatal incompetence and gastro-oesophageal reflux, the feedback system is recommended and the size of the intra-abdominal cuff should be stated.     

The association of intra-abdominal infection and abdominal wound dehiscence

Concurrent infection is a risk factor for abdominal wound dehiscence. We reviewed our experience with fascial dehiscence to determine the incidence and to identify prognostic factors for associated intra-abdominal infection. Over a 7-year period, 107 patients with abdominal wound dehiscence were identified. Seventeen were managed nonoperatively, and 90 underwent exploratory laparotomy, 43 of whom had no intra-abdominal pathology and 47 of whom had intra-abdominal infections. Demographic factors, comorbid diseases, and potential indicators of systemic infection did not distinguish patients with intra-abdominal infection from those without. Patients with an intra-abdominal infection were more likely to have undergone an emergency operation (74% vs 48%; P < 0.02), an operation on the colon (55% vs 25%; P < 0.005), or an operation with a higher wound classification (P < 0.02). Mortality was higher in patients with intra-abdominal infection than in those without (44% vs 20%; P < 0.02). Wound dehiscence after emergent operations, and operations with a higher wound classification, especially those involving the colon, should raise concern for intra-abdominal infection. Thorough abdominal exploration should be performed at the time of dehiscence repair. Before nonoperative management is chosen, intra-abdominal infection should be excluded.     

A case of acute hemorrhagic gangrenous acalculous cholecystitis with bile peritonitis during anti-coagulant therapy after coronary-artery bypass grafting

A 10-year-old male Domestic Longhair cat with weight loss, enlarged left testicle, icterus and mild liver enlargement showed, at necropsy, two white, raised, firm, circumscribed masses in the liver and striking enlargement of the left testicle. The histological features of the liver masses were consistent with lymphangioma. Severe, diffuse, coalescing to multifocal, subacute, necrotizing orchitis of the left testicle also was diagnosed. A literature review and examination of the epidemiology of lymphangioma in small domestic animals demonstrated the rarity of this tumour in cats.     

Evaluation of diagnostic peritoneal lavage in stable patients with gunshot wounds to the abdomen

BACKGROUND: Diagnostic peritoneal lavage (DPL) is used to diagnose intra-abdominal injury in patients with stab wounds and blunt trauma. Because exploratory celiotomy is routinely performed on patients with gunshot wounds to the abdomen, DPL is rarely employed. However, several studies have questioned routine exploration and have drawn attention to the associated morbidity of negative celiotomy. Diagnostic peritoneal lavage is an easily performed and inexpensive test that may be useful in this situation. OBJECTIVE: To evaluate the performance of DPL in the diagnosis of intra-abdominal injury in hemodynamically stable patients with gunshot wounds to the abdomen. DESIGN: A prospective clinical trial. SETTING: Two urban trauma centers. PATIENTS: Patients with gunshot wounds to the abdomen and a systolic blood pressure of at least 90 mm Hg. INTERVENTIONS: Clinical predication of intra-abdominal injury in the emergency department and DPL performed in the operating room before the initiation of celiotomy. Injuries found during the celiotomy were recorded. MAIN OUTCOME MEASURES: The results of the clinical evaluation and DPL were compared with the findings of the celiotomy. RESULTS: Forty-four patients were enrolled into the study. Intra-abdominal injury was present in 32 (73%) of these patients. The senior surgery resident correctly predicted the presence of intra-abdominal injury in 36 (82%) of the patients (sensitivity = 90.0%, specificity = 58.3%, positive predictive value = 85.3%, negative predictive value = 63.6%, phi = 0.52, P < .01) in the emergency department before DPL and celiotomy were performed. Diagnostic peritoneal lavage correctly identified the presence or absence of intra-abdominal injury in 40 (91%) of the patients (positive predictive value = 96.7%, negative predictive value = 78.6%, phi = 0.79, P < .01). CONCLUSIONS: Clinical judgment is highly accurate in separating patients with tangential gunshot wounds to the abdomen from those with intra-abdominal injury but may miss patients with intra-abdominal hemorrhage. Diagnostic peritoneal lavage is highly predictive of the presence of intra-abdominal injury. The return of gross blood on aspiration or a lavage red blood cell count greater than 10 x 10(9)/L should prompt an urgent celiotomy. Missed injuries are rare and most likely to be bowel perforations. Diagnostic peritoneal lavage is an objective test that may augment clinical judgment in selecting hemodynamically stable patients with potential tangential gunshot wounds for observation and is especially useful in identifying intra-abdominal hemorrhage.     

Fiberoptic bronchoscopic removal of intratracheal pledgetted repair sutures

The intrascrotal localization of lymphangioma in children is uncommon, especially when the lymphangioma does not depend on testicular structures. We present the case of a 13-year-old male who started with a right intrascrotal mass unconnected with the testicle, clinically and ultrasonically compatible with cystic lymphangioma. The mass was excised because of progressive growth over the previous 5 months, and at surgery a scrotal lymphangioma was disclosed projecting towards the umbilical area through the subcutaneous cell tissue of the anterior abdominal wall. There have been no complications or recurrences to date, 6 months afterwards. Surgical removal is the only efficacious therapeutic approach and is the best way to achieve a definitive diagnosis in these patients.     

Distribution of spermatogenesis in the testicles of azoospermic men: the presence or absence of spermatids in the testes of men with germinal failure

The aim of the study was to determine whether a prior diagnostic testicle biopsy can predict success or failure of testicular sperm extraction (TESE) with intracytoplasmic sperm injection (ICSI) in patients with non-obstructive azoospermia caused by testicular failure, and what is the minimum threshold of sperm production in the testis which must be surpassed for spermatozoa to reach the ejaculate. Forty-five patients with non-obstructive azoospermia caused by testicular failure underwent diagnostic testicle biopsy prior to a planned future TESE-ICSI procedure. The diagnostic testicle biopsy was analysed quantitatively, and correlated with the quantitative findings of spermatogenesis in patients with normal spermatogenesis, as well as with the results of subsequent attempts at TESE-ICSI. Men with non-obstructive azoospermia caused by germinal failure had a mean of 0-6 mature spermatids/seminiferous tubule seen on a diagnostic testicle biopsy, compared to 17-35 mature spermatids/tubule in men with normal spermatogenesis and obstructive azoospermia. These findings were the same for all types of testicular failure whether Sertoli cell only, maturation arrest, cryptorchidism, or post-chemotherapy azoospermia. Twenty-two of 26 men with mature spermatids found in the prior testis biopsy had successful retrieval of spermatozoa for ICSI, 12 of their partners became pregnant, and are either ongoing or delivered. The study suggests that 4-6 mature spermatids/tubule must be present in the testis biopsy for any spermatozoa to reach the ejaculate. More than half of azoospermic patients with germinal failure have minute foci of spermatogenesis which are insufficient to produce spermatozoa in the ejaculate. Prior diagnostic testicle biopsy analysed quantitatively (for the presence of mature spermatids) can predict subsequent success or failure with TESE-ICSI. Incomplete testicular failure may involve a sparse multi-focal distribution of spermatogenesis throughout the entire testicle, rather than a regional distribution. Therefore, it is possible that massive testicular sampling from many different regions of the testes may not be necessary for successful TESE-ICSI.     

Intrauterine unilateral torsion of the spermatic cord

A case of unilateral torsion of the spermatic cord in a newborn is reported. Extra-vaginal neonatal torsion of the spermatic cord, although rare, is being recognized with increasing frequency. Treatment requires immediate surgical exploration. Controversy exists concerning the urgency of exploration as well as the need for contralateral orchiopexy, since some reports suggest that the contralateral testicle is not a risk for torsion. Treatment of the ipsilateral testicle is determined by operative findings.     

Interaction of C-reactive protein with alpha-chain of interleukin-2 receptor

BACKGROUND: Approximately 5% of patients with testicular cancer harbour carcinoma in situ (CIS) in the contralateral testis. CIS will progress into invasive tumour in about 50% of cases within five years. The present study evaluated the effect of platinum containing chemotherapy on CIS. PATIENTS AND METHODS: Thirty-three patients with disseminated germ-cell cancer and biopsy proven CIS of the testis were evaluated. RESULTS: CIS had disappeared in the first follow-up biopsy in 30 patients. Six patients had a relapse of CIS with or without invasive cancer after 30, 31, 47, 51, 76 and 95 months from start of chemotherapy. Two relapses were among six patients who initially received cisplatin, vinblastine and bleomycine and four among 27 patients who initially received cisplatin, etoposide and bleomycine. The estimated cumulative risk of CIS five and 10 years after chemotherapy was 21% and 42%, respectively. The estimated cumulative incidence of spermatogenesis was 64% and 81% at five and 10 years of follow-up, respectively. CONCLUSION: Platinum containing chemotherapy may eradicate CIS. However, patients with CIS may develop invasive cancer in spite of chemotherapy. In the light of the present data, we recommend radiotherapy to the affected testicle in patients with CIS in the contralateral testis and in patients with bilateral testicular CIS. In patients with extragonadal disease and CIS in one testicle, orchiectomy of the affected testicle is recommended. In patients for whom future fertility is an important issue, follow-up including repeated biopsies can be offered for a period of at least 10 years.     

Diplegia of the laryngeal aperture after cranio-cerebral injury

In the testicle of Graphosoma italicum and Eurydema ventralis the histochemical localization of 3-beta-HSD, SDH, MDH and LDH was followed up. The enzymic activity was detected in various stages of the sexual cells; the strongest activity was found in the evoluted spermatids and spermatozoa. As far as the nutritive cells of the testicle are concerned, the reaction of these different enzymes appeared very weak or absent.     

Radiologic evaluation of gastrointestinal leiomyosarcomatosis

A 68-year-old woman who had previously undergone small intestinal resection because of leiomyosarcoma was referred to our clinic with epigastric pain. A double-contrast barium study and the subsequent abdominopelvic CT and abdominal MRI examinations demonstrated multiple extraluminal growing tumors arising from the walls of stomach, small bowel, and colon. A CT-guided aspiration biopsy revealed malignant mesenchymal tumor. The presence of disseminated intra-abdominal masses without concomitant ascites and invasion of tissue planes on CT in a patient operated on prior because of a leiomyosarcoma led to the diagnosis of gastrointestinal leiomyosarcomatosis. In this report we discuss the radiological approach to this rare entity.     

Relationship between volumes and areas from single transverse scans of intra-abdominal fat measured by magnetic resonance imaging

OBJECTIVE: To determine the level of a single transverse scan of intra-abdominal fat between L1 and L5 vertebrae that best predicts intra-abdominal fat volumes. SUBJECTS: Sixteen male and seven female patients with non-insulin-dependent diabetes mellitus, aged 44-74 y. OUTCOME MEASURES: Volumes and areas from single scans of intra-abdominal fat measured by magnetic resonance imaging with a 1.5 Tesla magnetic field strength. RESULTS: Intra-abdominal fat volumes and were calculated from fat areas from eight cross-sectional transverse single scans (nine scans in eight men) of 20 mm thickness. Men and women, respectively, had mean body mass index (BMI) of 27.9 (s.d. 3.0) and 31.6 (s.d. 4.7) kg/m2, and intra-abdominal fat of 2.3 (s.d. 0.5) and 2.5 (s.d. 0.6) kg. Intra-abdominal fat area of the fourth scan (in the direction of L1 to L5) gave the highest prediction of total intra-abdominal fat both in men (r = 0.959, P < 0.001) and in women (r = 0.973, P < 0.001). The intra-abdominal fat area of the third scan gave almost as good a prediction. These third and fourth scans corresponded to L2 and L3 vertebrae. The intra-abdominal fat areas from the sixth and seventh scans, corresponded to the frequently used L4-L5 and had lower correlations with intra-abdominal fat. There were no gender differences in the prediction of volumes from areas of intra-abdominal fat. Intra-abdominal fat areas of the fourth scan explained 93% of variance (SEE = 0.14 kg) of total of intra-abdominal fat for both genders: intra-abdominal fat (kg) = 0.0108 x intra-abdominal fat area of the fourth scan (cm2) + 0.244. CONCLUSIONS: In large studies of intra-abdominal fat, using magnetic resonance imaging (MRI) or computerised tomography scanning, a single intra-abdominal fat area at the intervertebral disc between L-2 and L-3 vertebrae offers a cheaper, faster and safer method, with high prediction of total intra-abdominal fat volumes and masses.     

Reversibility of alcoholic cardiomyopathy. II. Role of atrial fibrillation

A case of an unusual association between hernia and testicular infarction, namely torsion of a normally descended testis within a persistent processus vaginalis, is presented. The advantages of the inguinal ingulinal approach for the exploration of suspected torsion are discussed. Although an operation was performed more than 30 hours after the onset of symptoms the testicle was viable and recovered.     

Management of 53 cases of testicular trauma

Fifty-three patients with testicular injury were investigated. Four (8%) had bilateral testicular injury and 15 (28%) had associated injuries, such as penile, spermatic cord, epididymal disruption, thigh, urethral, perineal skin avulsion, femoral vessel disruption and axillary venous injury. The mode of testicle trauma was blunt in 36 (63%) and penetrating in 21 (37%) cases. Early exploration was done in 43 (81%) patients including 4 with bilateral testicular injury: hematoma evacuation in 23 (49%), partial orchiectomy in 16 (34%) and total orchiectomy in 8 (17%) cases, respectively. Otherwise, delayed exploration, due to the late presentation of more than 3 days after trauma, was done in the remaining 10 (19%) patients: hematoma evacuation in 6 (60%) and partial orchiectomy in 4 (40%) cases. The testicle salvage rate was 49/57 (86%), depending on the nature of testicular trauma. Hospitalization for uncomplicated cases was 4.82 +/- 1.85 days, with prolongation to 10.79 +/- 3.64 days (p < 0.05) for patients having associated injuries. Exploration is advocated in all cases of hematocele, irrespective of testicle contusion or rupture. As minimal, the blood-clot from the tunica vaginalis sac should be evacuated, which would relieve disability and hasten recovery.     

Laparoscopic cholecystectomy in the densely scarred abdomen

Extensive intra-abdominal adhesions are a possible contraindication to laparoscopic cholecystectomy and are known to occur after peritonitis because of perforated hollow viscus or multiple abdominal operations. Four such patients, who had undergone three or more previous abdominal operations, and had additional complicating factors, were successfully treated by laparoscopic cholecystectomy. An initial subxiphoid incision with blunt finger dissection was used to place the primary port. This approach achieves greater success and is safer than the traditional open umbilical dissection, because it avoids extensive lysis of small bowel and transverse colon adhesions from the anterior abdominal wall.     

Patterns of EEG alpha during word processing and relations to recall

The following relations were derived from large-scale testing of feed protein quality and its bearings on testicular function in growing Wistar rats: testicle weights and live weights r = 0.77 for juvenile animals and r = 0.36 for adult animals; nuclear volumes of Leydig's cells to testicle weights r = 0.84 for juvenile animals and r = 0.43 for adult animals; testosterone in testicular tissue, ng/g, to testicle weights r = 0.55 for juvenile animals and r = 0.80 for adult animals; testosterone per live weight, ng/100 g, to nuclear volumes of Leydig's cells r = 0.76 for juvenile animals and r = 0.46 for adult animals. Critical thresholds above which complete spermatogenesis is always ensured may be established for testosterone (50+/-5 ng/100 g live weight) and for the nuclear volume of Leydig's cells (30 mum3). Another conclusions drawn from the above results is that high testosterone levels in the testes of adult animals were not attributable to high testosterone biogenesis of Leydig's cells, as might have been assumed from high activities of that kind recordable from some nuclear volumes.     

Abdominal cystic lymphangiomas and mesenteric cysts: the clinical considerations

The authors present their experience about intra-abdominal lymphangiomas and mesenteric cysts. The histologic evidence shows that these lesions are different. An exact histologic diagnosis is important because lymphangiomas are more invasive and relapsing than mesenteric cysts. Of 8 cases founded at laparotomy, 6 were lymphangiomas and 2 mesenteric cysts. Larger lesions were caused by lymphangiomas (mean, 11 cm vs 6 cm) when compared with mesenteric cysts. Complete resection was possible in all 8 patients, without recurrence after a mean follow-up of 4 years.